adventures in public health and human rights

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Monthly Archives: June 2011

There’s a stupid anecdote about condoms that I have been hearing since the 1980s, and that I most recently heard last week. It is normally told at expat dinner parties, or by someone who has never been near a health promotion programme. If you are lucky you might find it on a comment thread below an article on overseas aid. It goes something like this:

I heard about an AIDS prevention/family planning programme that showed some Africans how to use condoms to prevent HIV/pregnancy by putting them on bananas/broom handles, and that when they went back to evaluate everyone was still getting HIV/pregnant but they found that all the bananas/broom handles had condoms on them.

I’m sure you’ve heard it too. The way it is normally told, it is very much about making the [presumably] illiterate villagers seem at best stupid and at worst beyond hope. The undertone often being that aid doesn’t work (even though you don’t need an aid programme to give out condoms), that Africa is a basket case…

Either way, apart from being racist, the story is bullshit. Firstly, as anyone who actually does health promotion knows, it’s actually quite hard to persuade people to do anything just by saying “do this”. Secondly, this is even more true when you are asking people to do something as weird as putting a condom on a broom handle (or a penis for that matter). Thirdly, and here’s where the monitoring and evaluation geekiness comes into it’s own, changes in outcomes like HIV infection simply can’t be observed that easily. So there.

But can the anecdote teach us anything about health promotion? Well, if anything like this ever has happened, it says much more about the people delivering the programme than about the beneficiaries. Unfortunately a lot of health promotion does take shortcuts: explaining the mechanics of conception or viral transmission to people with hardly any education is daunting. Perhaps in a programme like this one, beneficiaries weren’t told about sperm or penises but rather, the programme emphasised the importance of phallic objects being covered by latex. Sex can be hard to talk about openly too: but too many awkward euphemisms, not enough straightforward discussion, also help make discussions pretty ineffectual.

Lots of poor health promotion work operates like this – “nudging”, taking the path of least resistance, and not paying much attention to the people concerned – and in the long run it tends not to be helpful because it often deals with just one part of a much more complex set of determinants influencing the health problem in question. This article on sanitation in the Guardian, (which I also talked about in my last blog post) illustrates the problem well: “Several [people] described toilets as dirtier than the fields. The vast majority of facilities did not have soap for hand washing, which meant the expected health gains were lost… This lack of knowledge testifies to the failure of the education programme that makes up a critical component of the campaign. Most people did not realise that microscopic pathogens cause disease”.

Similarly, if you want to have an impact on HIV, you need to do more than increase condom use: in particular you also need to deal with reproductive health, STIs, gender norms, discrimination, and violence. Presumably the only pretend objective in the pretend programme described by the broom handle anecdote was to increase condom use. I’m also guessing that this pretend programme just involved people popping into the village, telling people to use condoms, and then leaving, rather than working in an ongoing way to improve the health and education system, and supporting individuals to figure out what was best for each of them.

Inasmuch as the anecdote allows us to imagine what might lead to such a poor outcome in health promotion, it may be a parable of sorts. But I don’t think it’s a particularly good one, because I think there are enough real examples of bad practice to be getting on with and more importantly, because I think it is malicious. I’m fed up of hearing it.

Update.

After this was posted, @DrPetra on twitter pointed out that this tale is a bit reminiscent of the constant undermining of sex education in the UK, a recent example being claims that 7 year olds are being taught how to put condoms on bananas… this claim seems unlikely, but even if it is true it is incredibly uncommon and not something most people involved in sex education would endorse. It’s easy to use individual horror stories to undermine a whole principle, but it is incredibly disingenuous.

What’s wrong with using emotional coercion as a means to achieving improved sanitation, asks this article on the Guardian’s development website, “given that the emotional coercion has been spearheaded by the local community itself?”The author describes how, during an evaluation exercise in Karnataka, India, she had seen a range of tactics employed to get people to use toilets:

At its mildest, this meant squads of teachers and youths, who patrolled the fields and blew whistles when they spotted people defecating. Schoolchildren whose families did not have toilets were humiliated in the classroom. Men followed women – and vice versa – all day, denying people the opportunity even to urinate…

Equally common, though, were more questionable tactics. Squads threw stones at people defecating. Women were photographed and their pictures displayed publicly. The local government institution, the gram panchayat, threatened to cut off households’ water and electricity supplies until their owners had signed contracts promising to build latrines. A handful of very poor people reported that a toilet had been hastily constructed in their yards without their consent…

…Often the education campaign devolved into sensationalist scare tactics, consciously intended to shock and terrify. These included graphic media stories on the rape-murders of women, and dramas about the dangers of child-snatching, robbery and snakebites while openly defecating (all rare in the area). In one village, a Unicef-sponsored NGO had even been showing people grotesque pictures of vast tumours and conjoined twins, suggesting they were the result of poor sanitation.

Many of the comments on the article appear to agree that the end justifies the means.Moreover, the legitimacy of the approach rests to a great extent on the fact that it comes from communities themselves: this is good old home-grown indigenous emotional coercion, not some neo-colonialist foreign-NGO imported emotional coercion.Government agents, foreign and local aid workers involved in sanitation can sleep easy in the knowledge that they aren’t imposing their own values.

Would this article have looked the same if it had been about AIDS rather than sanitation? The narrative of the utopian democratic upsurge is also a popular one in the global AIDS movement.And yet, the community sanitation work described in the article relies on powerful feelings of revulsion.If this approach was used to prevent HIV, programmes would be promoting rejection of people with HIV, homophobia, mandatory testing, and even incarceration of people perceived to be at risk.It would mean stigmatising any sexual behaviour perceived to be outside of the heterosexual, married norm, although this stigma would be disproportionately focussed on women rather than men.

In the case of AIDS, visceral feelings of revulsion make tackling it harder, not easier.Denial, fear, and the refusal of authorities to acknowledge the realities, mean people don’t get the information and the support they need. So a more common discourse is to emphasise the links between AIDS and human rights. It is not that simple. In the context of AIDS, powerful movements in defence of gay rights and the rights of drug users have captured the imagination of policy makers and activists, but there is still ambivalence when it comes to the rights of sex workers.At the same time the links between HIV and human rights are not always that clear. In some parts of West Africa it is the women who are the most socially marginalised who are the least affected by HIV. Even female genital mutilation and conflict are not categorically associated with higher HIV prevalence – in fact sometimes the opposite is true.

Does this mean FGM and conflict should be ignored? Of course not, since we don’t need an association with higher HIV prevalence to tell us we don’t want them. But what it does illustrate is that responding effectively to AIDS and many other global health and development problems is a messy business, and that it is nearly impossible to do without at some stage having to question what other people believe and what you believe.

It would be nice to think development projects are always respectful of the beliefs and approaches of the people they work with, but when working on issues where inequality and marginalisation play such a major role, it’s nearly impossible not to contradict this somewhere.I like to think that this is acceptable providing that for every person you disagree with, you are agreeing with someone else who has less of a say.But it’s still a judgement call when all’s said and done. It’s never just about communities knowing best, and it’s never only about human rights.